Aqueous skin antisepsis before surgical fixation of open fractures (Aqueous-PREP): a multiple-period, cluster-randomised, crossover trial

BACKGROUND

Chlorhexidine skin antisepsis is frequently recommended for most surgical procedures; however, it is unclear if these recommendations should apply to surgery involving traumatic contaminated wounds where povidone-iodine has previously been preferred. We aimed to compare the effect of aqueous 10% povidone-iodine versus aqueous 4% chlorhexidine gluconate on the risk of surgical site infection in patients who required surgery for an open fracture.

METHODS

We conducted a multiple-period, cluster-randomised, crossover trial (Aqueous-PREP) at 14 hospitals in Canada, Spain, and the USA. Eligible patients were adults aged 18 years or older with an open extremity fracture treated with a surgical fixation implant. For inclusion, the open fracture required formal surgical debridement within 72 h of the injury. Participating sites were randomly assigned (1:1) to use either aqueous 10% povidone-iodine or aqueous 4% chlorhexidine gluconate immediately before surgical incision; sites then alternated between the study interventions every 2 months. Participants, health-care providers, and study personnel were aware of the treatment assignment due to the colour of the solutions. The outcome adjudicators and data analysts were masked to treatment allocation. The primary outcome was surgical site infection, guided by the 2017 US Centers for Disease Control and Prevention National Healthcare Safety Network reporting criteria, which included superficial incisional infection within 30 days or deep incisional or organ space infection within 90 days of surgery. The primary analyses followed the intention-to-treat principle and included all participants in the groups to which they were randomly assigned. This study is registered with ClinicalTrials.gov, NCT03385304.

FINDINGS

Between April 8, 2018, and June 8, 2021, 3619 patients were assessed for eligibility and 1683 were enrolled and randomly assigned to povidone-iodine (n=847) or chlorhexidine gluconate (n=836). The trial's adjudication committee determined that 45 participants were ineligible, leaving 1638 participants in the primary analysis, with 828 in the povidone-iodine group and 810 in the chlorhexidine gluconate group (mean age 44·9 years [SD 18·0]; 629 [38%] were female and 1009 [62%] were male). Among 1571 participants in whom the primary outcome was known, a surgical site infection occurred in 59 (7%) of 787 participants in the povidone-iodine group and 58 (7%) of 784 in the chlorhexidine gluconate group (odds ratio 1·11, 95% CI 0·74 to 1·65; p=0·61; risk difference 0·6%, 95% CI -1·4 to 3·4).

INTERPRETATION

For patients who require surgical fixation of an open fracture, either aqueous 10% povidone-iodine or aqueous 4% chlorhexidine gluconate can be selected for skin antisepsis on the basis of solution availability, patient contraindications, or product cost. These findings might also have implications for antisepsis of other traumatic wounds.

FUNDING

US Department of Defense, Canadian Institutes of Health Research, McMaster University Surgical Associates, PSI Foundation.

Unreamed Intramedullary Nailing Versus External Fixation for the Treatment of Open Tibial Shaft Fractures in Uganda: A Randomized Clinical Trial

OBJECTIVE

To compare unreamed intramedullary nailing versus external fixation for the treatment of Gustilo-Anderson type II and IIIA open tibial fractures admitted to a hospital in rural Uganda.

DESIGN

Randomized clinical trial.

SETTING

Regional referral hospital in Uganda.

PATIENTS

Fifty-five skeletally mature patients with a Gustilo-Anderson type II or IIIA open tibia shaft fracture treated within 24 hours of injury between May 2016 and December 2019.

INTERVENTION

Unreamed intramedullary nailing (n = 31) versus external fixation (n = 24).

MAIN OUTCOME MEASUREMENTS

The primary outcome was function within 12 months of injury, measured using the Function IndeX for Trauma (FIX-IT) score. Secondary outcomes included health-related quality of life (HRQoL) using the 3-level version of the 5-dimension EuroQol instrument (EQ-5D-3L), radiographic healing using the Radiographic Union Scale for Tibia (RUST) fractures score, and clinical complications.

RESULTS

Treatment with an intramedullary nail resulted in a 1.0-point higher [95% credible intervals (CrI), 0.1 to 1.9] FIX-IT score compared with external fixation. Results were similar for the secondary patient-reported outcomes, EQ-5D-3L and the visual analog scale component of the EuroQol instrument (EQ-VAS). RUST scores were not different between groups at any time point. Treatment with an intramedullary nail was associated with a 22.1% (95% CrI, -42.6% to 1.7%) lower rate of malunion and a 20.8% (95% CrI, -44.0% to 2.9%) lower rate of superficial infection.

CONCLUSION

In rural Uganda, treatment of open tibial shaft fractures with an unreamed intramedullary nail results in marginal clinically important improvements in functional outcomes, although there is likely an important reduction in malunion and superficial infection.

LEVEL OF EVIDENCE

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Effect of Intrawound Vancomycin Powder in Operatively Treated High-risk Tibia Fractures: A Randomized Clinical Trial

Importance

Despite the widespread use of systemic antibiotics to prevent infections in surgically treated patients with fracture, high rates of surgical site infection persist.

Objective

To examine the effect of intrawound vancomycin powder in reducing deep surgical site infections.

Design, Setting, and Participants

This open-label randomized clinical trial enrolled adult patients with an operatively treated tibial plateau or pilon fracture who met the criteria for a high risk of infection from January 1, 2015, through June 30, 2017, with 12 months of follow-up (final follow-up assessments completed in April 2018) at 36 US trauma centers.

Interventions

A standard infection prevention protocol with (n = 481) or without (n = 499) 1000 mg of intrawound vancomycin powder.

Main Outcomes and Measures

The primary outcome was a deep surgical site infection within 182 days of definitive fracture fixation. A post hoc comparison assessed the treatment effect on gram-positive and gram-negative-only infections. Other secondary outcomes included superficial surgical site infection, nonunion, and wound dehiscence.

Results

The analysis included 980 patients (mean [SD] age, 45.7 [13.7] years; 617 [63.0%] male) with 91% of the expected person-time of follow-up for the primary outcome. Within 182 days, deep surgical site infection was observed in 29 of 481 patients in the treatment group and 46 of 499 patients in the control group. The time-to-event estimated probability of deep infection by 182 days was 6.4% in the treatment group and 9.8% in the control group (risk difference, -3.4%; 95% CI, -6.9% to 0.1%; P = .06). A post hoc analysis of the effect of treatment on gram-positive (risk difference, -3.7%; 95% CI, -6.7% to -0.8%; P = .02) and gram-negative-only (risk difference, 0.3%; 95% CI, -1.6% to 2.1%; P = .78) infections found that the effect of vancomycin powder was a result of its reduction in gram-positive infections.

Conclusions and Relevance

Among patients with operatively treated tibial articular fractures at a high risk of infection, intrawound vancomycin powder at the time of definitive fracture fixation reduced the risk of a gram-positive deep surgical site infection, consistent with the activity of vancomycin.

Trial Registration

ClinicalTrials.gov Identifier: NCT02227446.

The Feasibility of a Randomized Controlled Trial for Open Tibial Fractures at a Regional Hospital in Uganda

BACKGROUND

The inclusion of low and middle-income country (LMIC) hospitals in multicenter orthopaedic trials expands the pool of eligible patients and improves the external validity of the evidence. Furthermore, promoting studies in LMIC hospitals defines the optimal treatments for low-resource settings, the conditions under which the majority of musculoskeletal injuries are treated. The objective of this study was to determine the feasibility of a randomized controlled trial comparing external fixation with intramedullary (IM) nailing in patients with an isolated open tibial fracture who presented to a regional hospital in Uganda.

METHODS

From July 2016 to July 2017, skeletally mature patients who presented to a Ugandan regional hospital with an isolated Gustilo-Anderson type-II or IIIA open fracture of the tibial shaft were eligible for inclusion. The primary feasibility outcomes were the enrollment rate, the recruitment rate, and the 3 and 12-month follow-up rates. The secondary outcomes included a comparison of 3 and 12-month follow-up rates between the treatment arms and a qualitative assessment of barriers to enrollment, timely treatment, and missed follow-up.

RESULTS

During the 12-month enrollment period, 37.5% (30 of 80) of eligible patients were successfully enrolled and operatively treated on the basis of their random allocation, with an enrollment rate of 2.5 patients per month. Of the 30 enrolled patients, 53% completed their 3-month follow-up appointment, and 40% completed their 1-year follow-up appointment. Rates of 1-year follow-up were significantly higher for patients receiving IM nails than for those receiving external fixation (absolute difference, 52%; 95% confidence interval [CI], 21 to 83, p < 0.01). The main reasons that patients declined to participate in the trial were preferences for treatment by traditional bonesetters and prehospital delays that were related to a disorganized referral system. Barriers to follow-up included prohibitive transportation costs and community pressure to turn to traditional forms of treatment.

CONCLUSIONS

A regional hospital in Uganda can successfully enroll, randomize, and operatively treat multiple patients with an open tibial fracture each month. Patient follow-up presents substantial concerns over trial feasibility in this setting. Cultural pressure to utilize traditional treatments remains a particularly common barrier to study-participant enrollment and retention.

Association Between 6-Week Postdischarge Risk Classification and 12-Month Outcomes After Orthopedic Trauma

Importance

Numerous studies have demonstrated that long-term outcomes after orthopedic trauma are associated with psychosocial and behavioral health factors evident early in the patient's recovery. Little is known about how to identify clinically actionable subgroups within this population.

Objectives

To examine whether risk and protective factors measured at 6 weeks after injury could classify individuals into risk clusters and evaluate whether these clusters explain variations in 12-month outcomes.

Design, Setting, and Participants

A prospective observational study was conducted between July 16, 2013, and January 15, 2016, among 352 patients with severe orthopedic injuries at 6 US level I trauma centers. Statistical analysis was conducted from October 9, 2017, to July 13, 2018.

Main Outcomes and Measures

At 6 weeks after discharge, patients completed standardized measures for 5 risk factors (pain intensity, depression, posttraumatic stress disorder, alcohol abuse, and tobacco use) and 4 protective factors (resilience, social support, self-efficacy for return to usual activity, and self-efficacy for managing the financial demands of recovery). Latent class analysis was used to classify participants into clusters, which were evaluated against measures of function, depression, posttraumatic stress disorder, and self-rated health collected at 12 months.

Results

Among the 352 patients (121 women and 231 men; mean [SD] age, 37.6 [12.5] years), latent class analysis identified 6 distinct patient clusters as the optimal solution. For clinical use, these clusters can be collapsed into 4 groups, sorted from low risk and high protection (best) to high risk and low protection (worst). All outcomes worsened across the 4 clinical groupings. Bayesian analysis shows that the mean Short Musculoskeletal Function Assessment dysfunction scores at 12 months differed by 7.8 points (95% CI, 3.0-12.6) between the best and second groups, by 10.3 points (95% CI, 1.6-20.2) between the second and third groups, and by 18.4 points (95% CI, 7.7-28.0) between the third and worst groups.

Conclusions and Relevance

This study demonstrates that during early recovery, patients with orthopedic trauma can be classified into risk and protective clusters that account for a substantial amount of the variance in 12-month functional and health outcomes. Early screening and classification may allow a personalized approach to postsurgical care that conserves resources and targets appropriate levels of care to more patients.

Monitoring regional geriatric assessment teams: analysis of client flows and outcomes

The Commonwealth Government funding of the Geriatric Assessment Program began in 1984. The Program included an evaluation component, and this paper reports findings for three Regional Geriatric Assessment Teams (RGATs) in Victoria focusing on (1) the identification of different starting points in the flow of clients to the RGATs, (2) the relationships between different starting points and (3) recommended care plans, and the relationships between (2) and final outcome, particularly whether or not this involved admission to nursing home care. The role performed by RGATs is reviewed in the context of introducing mandatory assessment, the success of which will depend on the effectiveness of RGATs not only in differentiating need for and securing admission to nursing home care but also in assessing for, accessing and initiating alternative services.

Recent developments in aged care policy in Australia

A series of major reforms implemented through the mid 1980s sought to contain residential care and expand community care in Australia's long-term care system. While this goal has been maintained, a number of new policy initiatives followed the change of federal government in 1996. This article presents a systematic account of current policy objectives, implementation measures, and outcomes in three major policy areas: changing the balance between residential and community care, targeting in community care, and support for family caregivers. This analysis shows that while there have been shifts in emphasis from time to time, concerted policy efforts over the last 20 years have contained the growth of expenditure on long-term care and realized significant change in the service system.

Rearranging the compartments: the financing and delivery of care for Australia's elderly

Aged care policy in Australia underwent rapid change following the 1996 change of federal government, although continuing to emphasize changing the balance of aged care away from residential care toward community-based care and improving quality of care. This paper examines these policy directions with reference to two specific areas: the differentiation of funding arrangements for the care and accommodation components of residential care, and the targeting of services in community care. In both cases, funding arrangements have been used as a prime mechanism for redrawing the boundaries between different components and levels of care. This process of compartmentalization appears likely to increase the diversity of the Australian aged care system in the future.

Caregiving: a common or uncommon experience?

The analysis reported here aims to establish the household prevalence of caregiving in Australia, drawing on a large scale, longitudinal survey conducted as part of the Victorian Carers Project. Comparisons are made with a national survey conducted by the Australian Bureau of Statistics and with Canadian and U.K. findings. Three aspects of caregiving are investigated: reported household prevalence, taking account of differences in definitions used in various surveys; the extent of intergenerational exchanges involved in caregiving; and the time dimensions of caregiving, in terms of duration and patterns of cessation of caregiving over time. A high degree of consistency is found in prevalences of caregiving and implications for the development of policies and programs to support caregivers are raised concerning levels of caregiving, approaches to identifying carers, targeting of services and promotion of caregiving, and the spread of the experience of caregiving across the lifecycle and between generations.

From states of confusion to a national action plan for dementia care: the development of policies for dementia care in Australia

The release of Australia's National Action Plan for Dementia Care in 1992 was the culmination of more than a decade of policy development over which the federal government assumed an increasing role, and the participatory approach fostered under its Social Justice Strategy promoted collectivist and political attempts to address the issues of dementia care. This article begins with an account of four phases of policy development, with the transition from one to the next marked by changes in thinking about dementia care being incorporated into policy and then expressed in programmes and in care practices. In the second part of the article, the goals and structure of the National Action Plan are outlined and its implementation and outcomes discussed. Continuation of the policy climate in which the National Action Plan was formulated is a crucial, but uncertain, factor for future development.

Older women in an aging world: achieving health across the life course

This article, based on a report (Women, aging and health: achieving health across the life span) prepared for the WHO Global Commission on Women's Health under the guidance of WHO's Aging and Health Programme, presents demographic data that clearly demonstrate the need for recognition of the health of aging women as a global issue of major public health concern. The authors show that, while female life expectancy at birth is significantly different in developed and developing countries (because of high infant and maternal mortality in the latter), these differences tend to decrease for women in developing countries who reach middle age. The authors review the various facets of the "gender transition" brought about by demographic and epidemiological transitions, drawing attention to contrasts between the situation in developing countries in Asia and Latin America and that in Eastern Europe, for example. The role of older women as care-givers is discussed, as is the likelihood of a future increase in the proportion of older women living alone in the developing world (a factor which renders them particularly vulnerable in many socioeconomic and health respects). Suggestions are made on methodologies for monitoring health trends in aging women, and on the role of WHO in this respect. A basic goal for global strategies relating to the health of older women is formulated: reduction of the inequities in life expectancy between developed and developing countries.

The old old or the new old? Part 2--health status and trends of the population aged 80 years and over

"This paper is the second part of a study of the old old population, those aged 80 years and older, in Australia. It poses the question, as the experience of advanced old age becomes increasingly the norm, are more people living longer because of better health, or surviving longer in poorer health? Three aspects of population health are examined: patterns and trends in mortality, the morbidity implications of these findings, and service utilization. The study identifies a need to integrate analyses of mortality, morbidity and service use, and to develop a methodology able to express the diversity of the old old population."

Analysing access to nursing home care

The aim of this study is to investigate access to nursing home care in selected regions of Australia, Canada and the United States, and to examine the common ways in which nursing homes are used. Firstly, a review of methodological considerations in measuring access to nursing home care is made. Secondly, patient turnover patterns are interpreted with a view to showing differences in nursing home use among the countries studied; aggregate turnover rates, length of stay and outcomes are compared. Thirdly, groups of patients who differ in demographic and morbidity characteristics and in their use of nursing homes are discussed. Finally a number of distributive implications of these results are raised and a framework is outlined for considering redistributive consequences of changes in the use of nursing homes. It is concluded that the rate of flow of patients through nursing homes is as important a determinant of access to nursing home care as the level of bed provision and that adoption of this dynamic view of access indicates considerable scope for redistributing use of resources within the nursing home systems of all three countries.